Neonatal Intensive Care Unit Quality Research Articles

Building a NICU quality & safety infrastructure

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.

The PLAY bundle for head deformities: A NICU quality improvement project

BackgroundPremature infants in the Neonatal Intensive Care Unit (NICU) have a greater risk of head deformities and related complications. Numerous evidence-based interventions demonstrate successful prevention and treatment for head deformities with maximized success when combined. Local problemThere was no standardized policy to aid in the prevention, evaluation, and management of head deformities at a local children's hospital. Additionally, the Electronic Health Record (EHR) did not optimize head measurement documentation and documented asymmetrical head measurements did not prompt follow-up. MethodsAuthors developed a nurse-driven order set, or bundle, comprised of Positioning and PT/OT involvement, Learning, Assistive Devices, and You (PLAY) as part of a quality improvement project to reduce the progression of head deformities through education, prevention strategies, and earlier identification and treatment. Data collected for the first 13 weeks was under the current standard of care and data collected under the second 13 weeks was under the PLAY bundle. Results33 infants participated with 19 after PLAY Bundle implementation. Under the current standard of care, 34% of patients (n = 27) had plagiocephaly documentation while just 7% (n = 6) received a PT (Physical Therapist) consultation. Of the participants diagnosed with head deformities since PLAY Bundle implementation, biweekly head measurements improved in 58%, worsened in 20%, worsened then improved in 8%, and stayed the same in 20%. ConclusionsThe PLAY Bundle was successful in the earlier identification and intervention of head deformities. In addition, the PLAY Bundle highlighted the importance of repositioning intervention for head deformities.

Feeding volume advancement in preterm neonates: A level 4 neonatal intensive care unit quality improvement initiative.

Because of provider variability in feeding guideline application, a quality improvement (QI) initiative was begun to better standardize feeding initiation and advancement for preterm infants. Our specific, measurable, achievable, relevant, and timely aims included decreasing the time to reach full feeds by 35% and reducing the duration of central lines by 30% over 12 months in infants born between 25 and 30 weeks' gestation or with birth weight between 600 and 1250 g. Registered dietitians tracked central line days, parenteral nutrition (PN), enteral nutrition, fortification, guideline adherence, anthropometrics, necrotizing enterocolitis (NEC) cases, and central line-associated bloodstream infections (CLABSIs). QI progress charts were reviewed monthly. Mean central line days decreased from 7.3 to 5.8. Days of PN decreased from 6.7 to 5.1. The day of life that enteral feeds were started decreased from 1.1 to 0.5. The number of days between starting enteral feeds and adding fortification decreased from 3.4 to 2.3 days. Full enteral feeds were achieved on average 2 days earlier. Birth weight was regained at around 10.2 days of life before the guideline was implemented and at a mean of 9.6 days after the guideline. There was no increase in cases of CLABSI or diagnoses of NEC. After implementation of this feeding QI initiative at a level 4 neonatal intensive care unit, central line duration and PN use were decreased and infants reached full enteral feeds earlier without changes in cases of NEC, CLABSI, or time to regain birth weight.

Neonatal Intensive Care Quality Level-Dependent Variations in the Survival Rate of Infants with a Birth Weight of 500 g or Less in Korea: A Nationwide Cohort Study

Objective: Recent evidence suggests that the survival of peri-viable infants with birth weight (BW) ≤500 g could be improved with better care practices in the neonatal intensive care unit (NICU). This study aimed to investigate the care quality level of NICU-dependent variations in the survival rate of infants with BW ≤500 g. Methods: To determine the quality of NICU care-dependent variations in the survival rate, 226 eligible infants of BW ≤500 g and ≥22 weeks gestation registered in the Korean Neonatal Network between 2013 and 2017 were grouped according to the survival rates of infants at 23–24 weeks gestation, reflecting the care quality level of each NICU as group I (≥50%, n = 107) and group II (<50%, n = 119). Results: The survival rate of group I infants (40.2%, 43/107) was significantly higher than that of group II infants (14.3%, 17/119). Significantly reduced deaths from birth to the age of 7 days due to cardiorespiratory causes were the primary contributors to improved survival. In multivariable Cox hazard model analyses, besides the gestational age and BW, antenatal steroid use, cesarean section, pH, and base excess at admission were associated with improved infant survival. Conclusions: The survival rate of pre-viable infants with BW ≤500 g could be improved by providing better NICU quality care practices, including better cardiorespiratory management starting from delivery room resuscitation.

Evaluating Care in Safety Net Hospitals: Clinical Outcomes and Neonatal Intensive Care Unit Quality of Care in California

To examine the characteristics of safety net (sn) and non-sn neonatal intensive care units (NICUs) in California and evaluate whether the site of care is associated with clinical outcomes. This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22 081 infants born between 2014 and 2018 with a birth weight of 401-1500g or gestational age of 22-29weeks. Quality of care as measured by the Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs. Black and Hispanic infants were cared for disproportionately in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-Measure Of Neonatal InTensive care Outcomes Research (MONITOR) scores (z-score [SD]: snNICUs, -0.31 [1.3]; non-snNICUs, 0.03 [1.1]; P=.1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 [1.0] vs 0.27 [0.9]), lower rates of no health care-associated infection (-0.27 [1.1] vs 0.14 [0.9]), and higher rates of no hypothermia on admission (0.39 [0.7] vs -0.25 [1.1]). We found small but significant differences in survival without major morbidity (adjusted rate, 65.9% [95% CI, 63.9%-67.9%] for snNICUs vs 68.3% [95% CI, 67.0%-69.6%] for non-snNICUs; P=.02) and in some of its components; snNICUs had higher rates of necrotizing enterocolitis (3.8% [3.4%-4.3%] vs 3.1% [95% CI, 2.8%-3.4%]) and mortality (95% CI, 7.1% [6.5%-7.7%] vs 6.6% [6.2%-7.0%]). snNICUs achieved similar performance as non-snNICUs in quality of care except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

A Multisite Survey of NICU Healthcare Professionals' Perceptions About Family-Centered Care.

Family-centered care contributes to improved outcomes for preterm and ill infants. Little is known about the perceptions of neonatal intensive care unit (NICU) healthcare professionals regarding the degree to which their NICU practices or values family-centered care. The aims of this study were to describe attitudes and beliefs of NICU healthcare professionals about family-centered care and to explore professional characteristics that might influence those views. Data were derived from the baseline phase of a multicenter quasi-experimental study comparing usual family-centered NICU care with mobile-enhanced family-integrated care. Neonatal intensive care unit healthcare professionals completed the Family-Centered Care Questionnaire-Revised (FCCQ-R), a 45-item measure of 9 core dimensions of Current Practice and Necessary Practice for family-centered care. A total of 382 (43%) NICU healthcare professionals from 6 NICUs completed 1 or more of the FCCQ-R subscales, 83% were registered nurses. Total and subscale scores on the Necessary Practice scale were consistently higher than those on the Current Practice scale for all dimensions of family-centered care (mean: 4.40 [0.46] vs 3.61 [0.53], P < .001). Only years of hospital experience and NICU site were significantly associated with Current Practice and Necessary Practice total scores. Ongoing assessment of the perceptions of NICU healthcare professionals regarding their current practice and beliefs about what is necessary for the delivery of high-quality family-centered care can inform NICU education, quality improvement, and maintenance of family-centered care during the COVID-19 pandemic. Further research is needed to identify additional factors that predict family-centered care perceptions and behaviors.

Reducing antimicrobial prescribing errors, in the neonatal intensive care unit, Women's Hospital, Hamad Medical Corporation

Background and objective: Neonatal intensive care unit (NICU) is the unit rendering healthcare service for ill or premature newborn infants. Neonates are considered very high-risk patients and consequently they are more impacted by any prescribing error. On the other hand, prescribing errors are more common in pediatrics and in particular in NICU due to frequent changes in medication's dose and frequency based on postnatal age/weight; or due to immature organ function that alters drugs' absorption or excretion rate 1. Accordingly, identifying and reducing potential causes of prescribing errors in NICUs is a major patient safety priority. The objective is to reduce the frequency of antimicrobial prescribing errors in NICU, Women's Hospital, HMC by 50% versus base line (NICU medication error reported not to exceed 10% of total Women's Hospital medication errors reported) in 10 months (May 2015–January 2016). Methodology: We implemented quality improvement methodology PDSA to make improvements in the prescribing process, focusing on making an entire NICU quality outcome better consistently. Our quality improvement principle focused on the systems that created the current outcome. What NICU prescribers are doing is getting us what we are getting. To GET something different, we have to DO something different. Two PDSA cycles have been performed: PDSA 1 (April–May 2015) *NICU medication errors data have been shared with Quality and Patient Safety Committee and NICU department. * Improvement team was formed to initiate quality improvement intervention for NICU antimicrobial prescribing error trending. * Schedule Series of interactive educational sessions were provided by NICU clinical pharmacist. To NICU physicians, the aim of those sessions was to ensure full understanding of the Antimicrobial Dosing Chart by physicians. * Studying the quality improvement, the team decided to roll out PDSA 2 cycle. PDSA 2 (July–September 2016) * Creating a Mini Quick reference of the antimicrobial chart to be easily referred by the physician if needed in any prescribing issue. * Sharing the chart with NICU physicians. Result: Intervention led to a slight primary progress. Studying this progress 10 month projection, the team identified low probability to reach the improvement forecasted. PDSA 2 intervention significantly enhanced the progress leading to 50% less reports including antimicrobial prescribing errors – coming from NICU. Significant reduction of NICU antimicrobial prescribing errors reflected improvement in total NICU medication error reports as a percentage of the hospital reports. Conclusion: Antimicrobial prescribing errors reporting trend has negatively impacted the overall NICU service quality. Implementing quality improvement project: two cycles of PDSA have reduced not only the antimicrobial prescribing error reports, but also the overall medication error reports in NICU.

Variation in quality report viewing by providers and correlation with NICU quality metrics.

To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality. Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts. The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time. Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.

Neonatal Nurses NICU Quality Improvement: Embracing EBP Recommendations to Provide Parent Psychosocial Support.

The neonatal intensive care unit (NICU) can be a stressful environment for infants, their families, and the healthcare team. There is an immediate need for neonatal nurses to embrace and translate the new National Perinatal Association recommendations for psychosocial support of NICU parents into clinical practice to demonstrate best practices for infants, their families, and the whole team. To summarize the current evidence-based practice recommendations and to provide suggestions for team members to develop strategies to adopt and implement them through quality improvement (QI) projects. Literature reviews were conducted by the original 6 National Perinatal Association workgroup teams and covered all levels of available evidence (eg, qualitative, quantitative, and clinical research, guidelines, and clinical and parental expertise). Evidence was synthesized to formulate this set of recommendations published in December 2015. We describe their applicability to the vital role of neonatal nurses, while elucidating QI projects that track measurements of change to translate these recommendations into practice. Neonatal nurses are in an ideal position to transform systems of support for NICU parents through the adoption of these recommendations at the bedside, and further to identify areas for QI to enhance implementation. Neonatal nurses are integral to problem solving and identifying QI strategies for translating these recommendations into NICU clinical practice to improve parent psychosocial support. This article disseminates evidence and encourages scientific investigation into various methods of supporting emotional health of NICU parents to create better health outcomes.

Neonatal Intensive Care Unit Quality Initiative: Identifying Preanalytical Variables Contributing to Specimen Hemolysis and Measuring the Impact of Evidence-Based Practice Interventions.

Blood specimen hemolysis is a major cause of sample recollection in the neonatal intensive care unit. We aimed to reduce the hemolysis rate from 6.3% at baseline to less than 4% within the 9 months' duration of the study. Intravenous infusion of lipid emulsion during sample collection, sample collection site, and blood sample transportation methods were investigated as possible contributors to hemolysis. Subsequently, two practice improvements were implemented: pausing lipid emulsion infusion prior to collection and slowing withdrawal rates through arterial catheters. Samples were more likely to be hemolyzed if they were collected during lipid infusion and subsequently transported by pneumatic tube or collected through an arterial catheter. Retrospective analysis demonstrated a decreased number of tests cancelled due to specimen hemolysis (3.5%) after our interventions. We identified three variables contributing to hemolysis and instituted two clinical practice interventions to significantly reduce test cancellations due to hemolysis.

Improving the Context Supporting Quality Improvement in a Neonatal Intensive Care Unit Quality Collaborative: An Exploratory Field Study.

Successful quality improvement (QI) requires a supportive context. The goal was to determine whether a structured curriculum could help QI teams improve the context supporting their QI work. An exploratory field study was conducted of 43 teams participating in a neonatal intensive care unit QI collaborative. Using a curriculum based on the Model for Understanding Success in Quality, teams identified gaps in their context and tested interventions to modify context. Surveys and self-reflective journals were analyzed to understand how teams developed changes to modify context. More than half (55%) targeted contextual improvements within the microsystem, focusing on motivation and culture. "Information sharing" interventions to communicate information about the project as a strategy to engage more staff were the most common interventions tested. Further study is needed to determine if efforts to modify context consistently lead to greater outcome improvements.

Response to the Call to Action: A National Picture of Breastfeeding Support Provided in Neonatal Intensive Care

<h2>Paper Presentation</h2><h3>Objective</h3> To measure the frequency of breastfeeding support by nurses and receipt of human milk by very low birth weight (VLBW) infants in the neonatal intensive care unit (NICU), which is not known and to determine if the numbers and qualifications of nurses, their professional practice environments, and the availability of lactation consultants increased the number of infants who received this care. <h3>Design</h3> Cross‐sectional, observational study. <h3>Setting</h3> One hundred four NICUs. <h3>Sample</h3> Participants included 6,060 nurse survey respondents, 15,233 infants who were card for by nurses on their last shifts worked, and 7,886 VLBW infants cared for in participating NICUs. <h3>Methods</h3> Secondary analysis was used to examine nurse survey data collected in 2008 from the parent study and infant hospitalization data from 104 NICUs in the Vermont Oxford Network (VON), an NICU quality collaborative. Analysis was conducted using bivariate and multiple general linear regression models. <h3>Results</h3> The majority (54%) were discharged on formula only. Few infants (6%) were discharged on exclusive human milk. The remaining infants (42%) received human milk mixed with fortifier or formula. Nurses reported providing breastfeeding support to one in five infants whose parents were present. Sixty percent of infants had parents present for part or the entire shift. Only half of the NICUs had a lactation consultant (51%). Significantly greater numbers of infants received breastfeeding support and human milk (<i>p</i> < .05) in NICUs with supportive professional practice environments, baccalaureate‐prepared nurses, and nurses with at least 5 years NICU experience. <h3>Conclusion/Implications for Nursing Practice</h3> National health care agencies including the U.S. Surgeon General and American Academy of Pediatrics have described breastfeeding and human milk as the normative standard for infant feeding and nutrition. However, the country is falling far short of the Surgeon General's recommendation for this high‐risk pediatric population. The findings suggest NICU nurses provide breastfeeding support around the clock, typically without a lactation consultant available. Our results demonstrate that nurses are essential to providing lactation care to NICU infants for whom the receipt of human milk is an issue of patient satisfaction, quality patient care, effectiveness, and survival.

Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures?

To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician). In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion. In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'. Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.

Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures?

Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures?

The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates

To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings. Cross-sectional study based on risk-adjusted nosocomial infection rates. NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008. One hundred twenty-six California NICUs and 10 487 VLBW infants. Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years. Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the κ statistic. Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89. The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.

Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR.

To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality. Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method. Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%). A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.

Assessment of surfactant use in preterm infants as a marker of neonatal intensive care unit quality

BackgroundProposed neonatal quality measures have included structural measures such as average daily census, and outcome measures such as mortality and rates of complications of prematurity. However, process measures have remained largely unexamined. The objective of this research was to examine variation in surfactant use as a possible process measure of neonatal quality.MethodsWe obtained data on infants 30 to 34 weeks gestation admitted with respiratory distress syndrome (RDS) within 48 hours of birth to 16 hospitals participating in the Pediatric Health Information Systems database from 2001-2006. Models were developed to describe hospital variation in surfactant use and identify patient and hospital predictors of use. Another cohort of all infants admitted within 24 hours of birth was used to obtain adjusted neonatal intensive care unit (NICU) mortality rates. To assess the construct validity of surfactant use as a quality metric, adjusted hospital rates of mortality and surfactant use were compared using Kendall's tau.ResultsOf 3,633 infants, 46% received surfactant. For individual hospitals, the adjusted odds of surfactant use varied from 2.2 times greater to 5.9 times less than the hospital with the median adjusted odds of surfactant use. Increased annual admissions of extremely low birth weight infants to the NICU were associated with greater surfactant use (OR 1.80, 95% CI 1.02-3.19). The correlation between adjusted hospital rates of surfactant use and in-hospital mortality was 0.37 (Kendall's tau p = 0.051).ConclusionsThough results were encouraging, efforts to examine surfactant use in infants with RDS as a process measure reflecting quality of care revealed significant challenges. Difficulties related to adequate measurement including defining RDS using administrative data, accounting for care received prior to transfer, and adjusting for severity of illness will need to be addressed to improve the utility of this measure.

Consistent Compliance with Guidelines for Expressed Breast Milk (EBM) Reduces the Risk of Administering a Mother's Potentially Infected Breastmilk to Another Infant in a Neonatal Intensive Care Unit (NICU)

ISSUE: Inconsistent confirmation of infant's identity before feeding has been associated with increase incidence of incorrect administration of EBM. Our Epidemiology and Infection Control Department set out to reduce the risk of infectious disease transmission to infant's from incorrect EBM feedings and develop guidelines for screening the donor mother in the event of EBM exposure. PROJECT: A Breastmilk Exposure Task Force was organized to evaluate the current EBM infection control and exposure guidelines and devised a plan to prevent further incidence of incorrect EBM administration in our 80-bed Level III NICU. A key intervention was the development of an EBM Audit Tool. This tool was used to verify that two Registered Nurse's (RN's) confirmed infant's identity with EBM identification. Both RN signatures were required similar to procedure used for blood transfusion verification prior to administration. We established a breastfeeding subcommittee to assist with weekly auditing and provided positive reinforcement and timely feedback to nursing staff. RESULTS: EBM audits began in May of 2005, which resulted in a compliance rate of 100% with the newly revised, evidence-based EBM guidelines. During the months of July and August 2005 there was a noticeable decrease in compliance to 80%. These results lead to aggressive auditing and staff education by infection control, NICU management and the lactation consultant. Weekly audits by breastfeeding subcommittee volunteers, monthly auditing by the Infection Control Practitioner, in-services and counseling by NICU Supervisor for failure to comply with guidelines have proved to increase compliance rates to 100%. Since applying these interventions there had been one EBM exposure in the month of September 2005 and none reported for the months of October, November, and December 2005. This multifaceted team approach was designed to reduce incidence of transmitting infectious diseases to neonates and provide guidelines for the nurse to follow in the event an infant receives the incorrect EBM. LESSONS LEARNED: Consistent compliance with guidelines for Expressed Breast Milk (EBM) reduces the risk of administering a mothers' potentially infected breastmilk to another infant. Development of a Breastfeeding Task Force was crucial to identifying the need for process improvement. Utilizing a standard audit tool to assess nurse's compliance with EBM guidelines provides the team with the information needed to make necessary changes in the practice of verifying infant's identity before feeding EBM. Due to the success of the interventions, auditing for compliance with EBM guidelines will continue to be a part of the NICU patient safety and quality improvement activities.

Using Organizational Assessment Surveys for Improvement in Neonatal Intensive Care

Problems with organizational culture, lack of or poor team communications, and conflict are often seen as barriers to improvement efforts. A survey measuring aspects of organizational culture was administered twice to staff in neonatal intensive care units participating in the Neonatal Intensive Care Unit Quality Improvement Collaborative Year 2000 collaborative. The surveys provided comparative data on coordination, teamwork and leadership, conflict management, unit leadership and unit culture. These data were summarized and fed back to NICU teams with guidance on their use. Interviews on the use of the survey were held with 12 medical directors and patient care leaders in 9 different NICUs. The findings indicated that all the units contacted saw themselves as committed to undertaking the organizational survey and using the results. Some units shared the data widely and initiated changes. Other units limited the distribution of data to the unit leadership. There was no apparent relationship between scores on the survey and activities undertaken. Several respondents credited the survey with helping to promote discussions about organizational and team issues. Future use of the survey should include additional materials to assist in disseminating the results to staff.